Fetal Infant Mortality Review Project Hillsborough County, Florida

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Fetal Infant Mortality Review ProjectHillsborough
County, Florida
Case Review Team Meeting Healthy Start Coalition
of Hillsborough County October 27, 2003
Leisa J. Stanley, PhD(c), MS Associate Executive
Director
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Fetal and Infant Mortality Trends
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Fetal and Infant Mortality Trends1992-2003

• Fetal Mortality
• Total rate has declined by 8.
• White rate has increased by 10.7.
• Black rate has declined by 31.
• Disparity between the two groups is still 1.5
  down from 2.4 in 1992.

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Fetal and Infant Mortality Trends1992-2003

• Infant Mortality
• Declined by 16.1.
• At one time, this decline was at 30.
• Increased by 17.5 between 2000 and 2003.
• The provisional rate is 9.3.
• The provisional white rate is 6.3.
• The provisional non-white rate is 18.8. This rate
  has increased by 163 since 1998.
• Racial disparity is 2.98.

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Fetal and Infant Mortality Trends1992-2001

• Neonatal Mortality
• Declined by 24.
• White rate has declined by 33.
• Black rate has increased by 7.5.
• Disparity is 2.5.
• Increase between 2000 to 2001, for both white and
  black infants

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Fetal and Infant Mortality Trends1992-2001

• Post-neonatal Mortality
• Rate has declined by 24.
• White rate has declined by 23.
• Black rate has declined by 16.
• However, since 1998 there has been a 126
  increase in the black rate (3.15 to 7.12)
• Disparity is at 3.3.
• This rate accounts for most of the increase in
  infant mortality.

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Cause of Death, 1998-2000
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Cause of Death, 1998-2000
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Cause of Death, 1998-2000

• Deaths due to Birth Defects
• Increase in 2000 due to Heart Defects
• 5 deaths due to Hypoplastic Left Heart Syndrome
  (usually is 1).
• 8 deaths due to Heart-Other (highest has been 3).
• Increase in 1999 due to Respiratory System
• 6 deaths due to Agenesis, Hypoplasia or Dysplasia
  of Lung (usually 2).

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Deaths due to Birth Defects 1998-2000

• White Women
• 71 died during neonatal period
• 29 were VLBW
• 31 were 1500-2500 g
• 64 were preterm
• 7 were multiples
• 17 were 34 yrs.
• 0 were teens
• 2.5 - No/Late PNC
• 10.3 - 2nd Trimester

• Black Women
• 59 died during neonatal period
• 24 were VLBW
• 41 were 1500-2500 g
• 47 were preterm
• 0 were multiples
• 12 were 34 yrs.
• 11.8 were teens
• 0 - No/Late PNC
• 31 - 2nd Trimester

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Deaths due to Perinatal Conditions 1998-2000

• White Women
• 94 died during neonatal period
• 80 were VLBW
• 4 were 1500-2500 g
• 89 were preterm
• 15 were multiples
• 16 were 34 yrs.
• 11.8 were teens
• 8 - No/Late PNC
• 11 - 2nd Trimester

• Black Women
• 88 died during neonatal period
• 92 were VLBW
• 1.4 were 1500-2500 g
• 97 were preterm
• 16 were multiples
• 5.3 were 34 yrs.
• 9.2 were teens
• 7.4 - No/Late PNC
• 4.4 - 2nd Trimester

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Deaths due to SIDS 1998-2000

• White Women
• 8.7 died during neonatal period
• 0 were VLBW
• 9 were 1500-2500 g
• 9 were preterm
• 4.315 were multiples
• 13 were 34 yrs.
• 8.7 were teens
• 8.6 - No/Late PNC
• 17 - 2nd Trimester

• Black Women
• 0 died during neonatal period
• 12.5 were VLBW
• 0 were 1500-2500 g
• 25 were preterm
• 12.5 were multiples
• 0 were 34 yrs.
• 0 were teens
• 0 - No/Late PNC
• 37.5 - 2nd Trimester

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2001-2002 Infant Death Record Abstractions

• There were a total of 265 infant deaths in both
  years.
• Cause of Death on Certificate
• 145 (55) due to Prematurity
• 19 (7.2) due to Sudden Infant Death Syndrome
• 17 (6.4) due to Congenital Anomalies
• 10 (3.8) due to Sepsis
• 6 (2.3) due to Suffocation/Asphyxia
• 2 (
• 6 (2.3) are Pending

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2001-2002 Infant Death Record Abstractions

• Areas with the highest concentration of infant
  deaths
• Brandon 12 (33510,33511)
• Plant City 10 (33566,33567)
• Sulphur Springs 13 (33604)
• Central Tampa 37 (33602,33603,33605,33610)
• University 24 (33612,33613)
• Town Country 15 (33614,33615,33634)
• Clair Mel 9 (33619)
• 33617 - 12

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SIDS Deaths 1998-2000

• Entire Cohort
• Of 34 deaths due to SIDS,
• 26 were white
• 8 were black
• 41 of infants were born at one hospital that
  delivers 19.3 of all births (p
• 70.6 of mothers had first trimester prenatal
  care 21 2nd and 8.8 late/no pnc (p
• 23.5 were 18-19 years old (p.003).
• 79.5 had

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SIDS Deaths 1998-2000

• 56.3 of mothers stated they wanted this
  pregnancy later or not at all (p.027).
• 29.4 were smokers (p
• 8.8 were
• 14.7 were
• Differences for live birth versus SIDS death
• 33.0243 g versus 3179.39 g, p.224.
• 38.64 weeks versus 38.18 weeks, p.285.
• Average age 84.42 days.

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Perinatal Periods of Risk
CityMatCH
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PPOR Phase 1Analyses

• Map fetal and infant deaths by weight and age at
  death for county and any target populations.
• Neonatal 27 days of life or less
• Post-Neonatal 28-364 days of life
• Fetal deaths 24 weeks
• Compare to referent group group with lowest
  feto-infant mortality rate
• White
• 20 years old
• 13 years of education

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Data Sources for PPOR Phase 1

• 1998-2000 Florida linked birth and infant death
  certificates
• 1998-2000 Florida fetal death certificates
• Inclusion Criteria
• maternal residents of Hillsborough County, FL at
  birth of infant
• birth weight 500 grams for all births
• gestation 24 weeks for fetal deaths
• Imputations of the birth weight / gestational
• age if possible

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Map Feto-Infant Mortality
AGE AT DEATH
PostNeonatal
Neonatal
Fetal
BIRTH WEIGHT
Maternal Health/Prematurity
500-1499 g
Maternal Care
Infant Health
1500 g
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Map Connections to Actions
Pre-conceptional Health Health Behaviors Perinatal
Care
Maternal Health/Prematurity
Prenatal Care Referral System High Risk OB Care
Maternal Care
Perinatal Management Referral System Specialty
Care (NICU)
NewbornCare
Sleep Position Breast-Feeding Injury Prevention
Infant Health
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Feto-Infant Mortality Hillsborough County,
Florida 1998-2000
PostNeonatal
Neonatal
Fetal
Maternal Health 4.0 (n178) W3.1 B7.4 RR2.39
500-1499 g
MaternalCare 2.7 (n117) W2.3B4.1 RR1.78
NewbornCare 1.6 (n71) W1.4B2.2 RR1.57
Infant Health 2.1 (n92) W1.8B3.3 RR1.83
1500 g
Total Feto-Infant Mortality Rate 10.3
feto-infant deaths per 1,000 live births fetal
deaths (n458). White rate8.5 Black rate 17.0
RR2.0
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Excess Mortality Opportunity Gap
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Fetal-Infant Mortality Rates Florida Practice
Collaborative, 1998-2000
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PPOR Phase II Analyses

• Additional analyses of Maternal Health Period of
  Risk to determine if excess mortality is due to
• Increases in Low Birth Weight Distributions, or
  increases in Infant Mortality Rates
• Additional analyses of Infant Care Period of Risk
  to determine cause of excess mortality
• Compare total county to referent group by each
  cause of death

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Maternal Health Period of Risk Kitagawa Analyses
Results

• Excess Mortality Due to Birth Weight Distribution
• 48.8 of the excess mortality
• 92 of the excess mortality in the
  Prematurity/Maternal Health Period of Risk
• Excess Mortality Due to Feto-Infant Mortality
  Rate
• 51.2 of the excess mortality
• Concentrated in infants born at 2,500 grams

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Infant Health Period of Risk
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Risk Factors by PPOR Domain
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Fetal Infant Mortality Review

• Infant mortality is the most sensitive index we
  possess of social welfare (Julia Lathrop,
  Childrens Bureau, 1913)

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FIMR Process

• Data Gathering
• Case Selection
• Exclusionary Criteria
• Selection Method
• Medical Records
• Home Interview
• Other Important Records
• Healthy Start
• Healthy Families
• Department of Children Families
• Hillsborough Kids, Inc.
• WIC
• Timeliness

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FIMR Process

• Case Review Process
• Cases, providers and hospitals are all
  de-identified
• Review of selected cases and de-identified
  summaries of those cases
• Review of aggregate data
• Patient names, provider names and hospitals may
  not be disclosed during meetings
• All materials related to case review are
  collected and destroyed at the end of the meeting

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FIMR Process

• What each case review contains
• The familys situation during the pregnancy or at
  the time of the loss
• What happened, from the familys standpoint, from
  the providers perspectives, and from that of
  other agencies
• Services or community resources the family was
  known to have received or not received
• Any events sine the loss that are relevant in the
  case

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FIMR Process

• What case reviews are intended to accomplish
  Determining underlying system issues that may
  have contributed to the fetal/infant death being
  reviewed.
• What economic, health service systems, community
  resources or personal factors helped this family?
• Did the family receive the services and resources
  that they needed?
• What are the local service delivery issues that
  the case highlights?
• Are there gaps in the system or community
  resources?
• Is it possible to design more responsive
  community resources or service delivery systems?
  What should they look like?

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FIMR Process

• What case reviews are not intended to accomplish
• Placing blame on provider (s) in the fetal or
  infant death
• Placing blame on the mother or family
• Be a research project

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FIMR Process

• Community Action
• Plan Development Committee
• Receives recommendations from the Technical
  Review Committee
• Plans for implementation of those recommendations
  in the community
• Changes in Community Systems

Fetal and Infant Mortality Review Manual A
Guide for Communities National Fetal and Infant
Mortality Review Program, 1998
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Floridas FIMR Results

• 231 cases reviewed from 12 counties
• Case Review Findings
• 49 Poverty (Medicaid status)
• 46 Maternal Infection and/or Sexually
  Transmitted Infection
• 46 Multiple Stresses during Pregnancy
• 44 Florida Healthy Start Screen Not
  Completed
• 31 Preterm Labor

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Floridas FIMR Results

• Case Review Findings (continued)
• 30 Late Entry into Prenatal Care
• 29 Tobacco Use
• 28 Florida Healthy Start Infant Screen Not
  Completed
• 23 Congenital Anomalies
• 22 Inadequate Patient Education
• 22 Cord Anomalies
• 21 Previous Fetal Loss
• 20 Maternal Obesity (19 Poor Nutrition)

FIMR 2001 Annual Report, Florida Department of
Health
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Next Steps

• Case selection process
• Exclusionary Criteria
• How cases will be selected
• When cases will be presented
• Ground rules for the meeting
• Meeting schedule date and frequency
• Sign Confidentiality Agreement